HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13 O -WD C- 6-82.-75 FEE 4�Z 100
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Nils COMMONWEALTH OF MASSAC14USETTS
Board of Health, ��� MA.
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APPLICATIONFOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Ap lication fora Permit to Construct( ) Repair(k Upgrade( ) Abandon( - ❑ Complete System
Individual Components
ocation '] C,o4c- jc
Owner's Name PA TR `c l a �w J
MOLL) O LL) J (
Address ( 5 A1, moiz, L Ki Uoiuq Gks- N MA
Lot#
Telephone#
Installer's NameAvc- t AE Eomaa,�5� L(C
Designer's Name
Address 1 rJ� C 0"Ofe-F41JAC ST M4514'P>`—
Address
Telephone# 568-q--77-92-7-7
Telephone#
Type of Building R GS (DEOT (A L-- Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other'- Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required)
Plan: Date
Title
Description of Soil (s)
gpd Calculated design flow
Number of sheets
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS R&P1-4ej1=-- D r Bo )e'
Design flow provided gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place a system in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �, 01-1 c7 qs
Inspections
NO. fi4iDC...((n
COMMONWEALTH OF MASSACHUSETTSlo�'e FEE � oG
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Board of Health,-(2.jY1C��T1-i MA, ��
CERTIFICATE Of COMPLIANCE°o�6y�
Description of Work: )l Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded( ), Abandoned (
C )
by: P'�4�4�1 AJ7E q!S
at
has been install c�l ecXaai(fe wrtn t ie?r`dvisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _�, dated 2 _ �. Approved Design Flow `— (gpd)
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Installer t,. A C.
Designer: Inspector: CXAl Date:
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. 50hY�� �,'"t�Z.1J CA PEFW iT)iF FEE
Ills COMMONWEALTH OF MASSAC14USETTS
Board of Health,- ftJ2 /Ih�i�l-i , MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(X Upgrade( ) Abandon( ) an individual sewage disposal system
at q (Aaig: LAmg- as described in the application for
Disposal System Construction Permit No. 101r,- dated � -:2 `l .
Provided: Construction shall be completed within thy, of the date of this permit. All local conditions must be met.
Form 1255. Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ..2 "l Jo/ Board of Health �� V�